Original Article

Antibiotic use and knowledge in the community of Yemen, Saudi Arabia, and
Uzbekistan

Tatyana Belkina1, Abdullah Al Warafi2, Elhassan Hussein Eltom3, Nigora Tadjieva4, Ales Kubena1, Jiri
Vlcek1
1
Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Kralove, Charles University, Prague,
Czech Republic
2
Faculty of Dentistry, Ibb University, Republic of Yemen
3
Department of Pharmacology, Faculty of Medicine, Northern Borders University, Arar, Kingdom of Saudi Arabia
4
Department of Infectious Diseases and Paediatrics, Tashkent Medical Academy, Tashkent, Republic of
Uzbekistan

Abstract
Introduction: Inappropriate use of antibiotics has resulted in a dramatic increase of antimicrobial resistance in developing countries. We
examined knowledge, attitudes, and practices of antibiotic use in three Asian countries.
Methodology: A nationwide cross-sectional study of teachers in large cities of Yemen, Saudi Arabia, and Uzbekistan was conducted. A
random sample of 1,200 teachers was selected in each country. Data were collected through a questionnaire-based survey and then analyzed
using descriptive and multivariate statistical methods.
Results: The prevalence of non-prescription antibiotic use ranged from 48% in Saudi Arabia to 78% in Yemen and Uzbekistan. Pharmacies
were the main source of non-prescribed antibiotics. The most common reasons for antibiotic use were cough (40%) and influenza (34%).
Forty-nine percent of respondents discontinued antibiotics when they felt better. Although awareness of the dangers of antibiotic use
correlated inversely with self-medication, understanding of the appropriate use of antibiotics was limited.
Conclusions: The prevalence of antibiotic self-medication in the educated adult population in the studied countries was found to be
alarmingly high. Effective strategies involving regulatory enforcement prohibiting sales of antibiotics without prescription should be
implemented along with educational interventions for health professionals and the public.

Key words: antibiotics; drug resistance; self–medication; developing countries

J Infect Dev Ctries 2014; 8(4):424-429. doi:10.3855/jidc.3866

(Received 11 June 2013 – Accepted 17 December 2013)

Copyright © 2014 Belkina et al. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.

Introduction antibiotic consumption appears to be increasing

Antimicrobial resistance is dramatically increasing
worldwide in response to inappropriate antibiotic use
[1]. Antimicrobial resistance to most common
pathogens has reached alarming levels in developing
countries, and trends show further increase. The main
reasons for the increase of antimicrobial resistance
include unregulated drug availability, inadequate
antimicrobial drug quality assurance, inadequate
surveillance, and widespread attitude to antimicrobial
misuse, including self-medication [2]. It is estimated
that approximately two-thirds of all oral antibiotics
used worldwide are obtained without a prescription
and are inappropriately used for diseases such as
tuberculosis, malaria, pneumonia, and for mild
childhood infections [3]. In less affluent countries,
steadily due to expanded population, rising incomes,
and improved access to health care. In contrast with
developed countries, where outpatient antimicrobials
are largely restricted to prescription-only use, non-
prescription access to antimicrobials is common in less
affluent countries, resulting in uncontrolled use and
self-medication [2,4,5].
Relatively few studies on antibiotic use in Western
and Central Asian countries are available, and
published data are scarce or absent. Here, we report on
a study performed in Yemen, Saudi Arabia, and
Uzbekistan on antibiotic use and knowledge in a
sample of educated adults.
Belkina et al. – Antibiotic use in three Asian countries
Methodology
Study design
A national population-based cross-sectional survey
was designed and conducted during November 2012 in
three countries of Western and Central Asia: Yemen,
Saudi Arabia, and Uzbekistan. The study’s participants
were 400 general education teachers from each
country. To perform multiple logistic regression
analysis, the total sample size was determined at 1,200
study subjects, owing to the large number of studied
variables. The selected cities were Ibb (Yemen),
Najran (Saudi Arabia), and Tashkent (Uzbekistan).
From the initial sample size of all secondary schools in
each of the cities, 10 schools were selected using the
probability proportional to size sampling technique.
Forty teachers were then randomly selected from the
list of employee names obtained from the school.
Respondents were interviewed based on the
questionnaire developed in English by the project
group of Charles University, Czech Republic. The
questionnaire was pre-tested and translated into the
local language of each country and then back-
translated into English to validate the translation. An
explanation of the purposes of the research and
assurance of anonymity was provided to participants
and verbal informed consent was obtained.
The questionnaire was administered to the
respondents face-to-face by public health research
assistants and consisted of three parts. Part one was
designed to evaluate the recent use of antibiotics in the
past three months, the source of the prescription, intent
to use antibiotics without consulting a physician,
reason for taking the antibiotic, and duration of use.
Part two of the questionnaire assessed knowledge and
attitudes towards antibiotics and storage of antibiotics
at home. Part three included the demographic
characteristics of the respondents such as sex, age, and
highest degree obtained (BS, MS, or other).
Statistical analysis
All data were analyzed using PASW Statistics
version 18. Descriptive results for the quantitative
variables were evaluated according to mean ± standard
deviation. Results regarding binary variables (sex,
questions with yes/no answers) were applied with
frequencies into percentages. Kendall’s correlation
was used to investigate association between ordinal
variables.
Simple statistical analysis verifying the difference
between countries in response to questions about the
respondent’s knowledge and attitude towards
antibiotics was estimated using contingency tables and
J Infect Dev Ctries 2014; 8(4):424-429.
frequency comparison. A generalized linear model
(Bernoulli distribution with logistic link function) was
used for more complex dependence of issues on the
summary of socio-demographic factors (gender, age,
country of respondent) and their interactions. The level
of statistical significance was set at p < 0.05.
Results
Four hundred residents in each state were
approached for participation. All of them provided
complete information. The demographic
characteristics of the respondents are presented in
Table 1. Most of the participants were females.
The prevalence rates of prescribed and non-
prescribed use of antibiotics are presented separately
for each country (Table 2). Among the respondents
ever treated with antibiotics, 31% reported using
prescribed antibiotics, while 69% reported non-
prescribed use following the recommendation of a
pharmacist or friend, their own initiative, or using a
leftover prescription. The prevalence rates for taking
antibiotics without a prescription were the highest in
Yemen and Uzbekistan and lower in Saudi Arabia,
where half of respondents preferred to use prescribed
antibiotics. The main source of non-prescribed
antibiotics in Yemen and Uzbekistan was pharmacies,
followed by a high rate of using a previous
prescription and administering alone in Saudi Arabia.
About 81% of respondents had used antibiotics in
the previous three months. Cough, influenza, and
gynecological inflammations were the most frequent
reasons, followed by gastrointestinal infections and
respiratory inflammations (Table 3). Treatment with
antibiotics for cough symptoms and influenza tended
to be the highest in Saudi Arabia and Yemen. In
Uzbekistan, respiratory inflammations were reported
as the main indications for antibiotics use.
Nearly 44% of respondents prescribed an
antibiotic completed the course; however, half
reported that they did not finish their last antibiotic
course as prescribed because they felt better. Seven
percent changed the antibiotic if did not make them
feel better (Table 4).
Country, age, and teacher education were
significantly associated with storage, attitudes, and
knowledge of antibiotic use, while gender had no
significant effect. The interaction with education can
be explained by different teacher education levels
among the studied states, where, along with an
advanced and bachelor’s degree, special secondary
education is eligible for a teaching certificate.
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Belkina et al. – Antibiotic use in three Asian countries J Infect Dev Ctries 2014; 8(4):424-429.

Table 1. Demographic characteristics of respondents

Yemen Saudi Arabia Uzbekistan Total
No. respondents (%) No. respondents (%) No. respondents (%) No. respondents (%)
Characteristics (N = 400) (N = 400) (N = 400) (N = 1200)
Gender
Male 161 (40.2) 64 (16.0) 186 (46.5) 411 (34.3)
Female 239 (59.8) 336 (84.0) 214 (53.5) 789 (65.8)
Age
< 20 73 (18.3) 42 (10.5) 58 (14.5) 173 (14.4)
20-30 190 (47.5) 110 (27.5) 102 (25.5) 402 (33.5)
31-40 114 (28.5) 202 (50.5) 87 (21.8) 403 (33.6)
41-60 21 (5.3) 44 (11.0) 89 (22.3) 154 (12.8)
> 60 2 (0.5) 2 (0.5) 64 (16.0) 68 (5.7)
Education
Master's/Ph.D. 15 (3.8) 42 (10.5) 169 (42.3) 226 (18.8)
Bachelor's degree 263 (65.8) 189 (47.3) 117 (29.3) 569 (47.4)
Secondary 122 (30.5) 169 (42.3) 114 (28.5) 405 (33.8)

Table 2. Source of antibiotics

Yemen Saudi Arabia Uzbekistan Total
No. (%) No. (%) No. (%) No. (%)
Prescribed (N = 367) (N = 353) (N = 369) (N = 1089)
By physician 80 (21.8) 182 (51.6) 80 (21.7) 342 (31.4)
No. (%) No. (%) No. (%) No. (%)
Non-prescribed (N = 287) (N = 171) (N = 289) (N = 747)
Pharmacist's advice 158 (55.1) 37 (21.6) 130 (45.0) 325 (43.5)
Friend's advice 21 (7.3) 33 (19.3) 53 (18.3) 107 (14.3)
Self 49 (17.1) 54 (31.6) 93 (32.2) 196 (26.2)
Old prescription 59 (20.6) 47 (27.5) 13 (4.5) 119 (15.9)

Table 3. Clinical indications for antibiotic use

Yemen Saudi Arabia Uzbekistan Total
No. (%) No. (%) No. (%) No. (%)
Reasons (N = 304) (N = 334) (N = 239) (N = 877)
Cough 125 (41.1) 175 (52.4) 53 (22.2) 353 (40.3)
Influenza 98 (32.2) 136 (40.7) 62 (25.9) 296 (33.8)
Respiratory inflammations 16 (5.3) 19 (5.7) 90 (37.7) 125 (14.3)
After surgery 14 (4.6) 3 (0.9) 14 (5.9) 31 (3.5)
Gastrointestinal 81 (26.6) 18 (5.4) 27 (11.3) 126 (14.4)
Gynecological inflammations 86 (28.3) 181 (54.2) 12 (5.0) 279 (31.8)
Orthopedic inflammations 21 (6.9) 10 (3.0) 17 (7.1) 48 (5.5)
Urinary inflammations 15 (4.9) 6 (1.8) 20 (8.4) 41 (4.7)
Ear infection 25 (8.2) 2 (0.6) 18 (7.5) 45 (5.1)
Other - 1 (0.3) 23 (9.6) 24 (2.7)

Table 4. Self-reported principles of antibiotic use

Yemen Saudi Arabia Uzbekistan Total
No. (%) No. (%) No. (%) No. (%)
Statement (N = 367) (N = 353) (N = 369) (N = 1089)
I stop taking the antibiotic when I feel better 163 (44.4) 137 (38.8) 236 (64.0) 536 (49.2)
I change the antibiotic if do not feel better immediately 14 (3.8) 46 (13.0) 15 (4.1) 75 (6.9)
I take antibiotics as prescribed by my 190 (51.8) 170 (48.2) 118 (32.0) 478 (43.9)
physician/pharmacist

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Belkina et al. – Antibiotic use in three Asian countries
Respondents from Yemen and Saudi Arabia that
were more likely to self-medicate with antibiotics
were younger women (p = 0.010) and those with a
lower level of education (p = 0.017), whereas in
Uzbekistan, age and education did not affect self-
medication.
Almost 46% of respondents with higher
preponderance in Saudi Arabia reported that they
retain antibiotics at home regardless of the source. A
significant relationship was found between storage and
country and age (p < 0.001). Being younger and less
educated in Yemen and Saudi Arabia was associated
with keeping inventory at home. In contrast, older
respondents in Uzbekistan reported appropriate
storage of antibiotics.
Respondents’ knowledge of antibiotic bacteria
resistance were assessed; typically, knowledge was
found to increase with age in all the studied countries
(p = 0.031). Paradoxically, however, more educated
respondents were less knowledgeable about bacteria
resistance in Yemen. Similar results were obtained
regarding the statement “awareness that antibiotics kill
off the normal flora” (country vs. education p < 0.001).
Respondents in Yemen with lower qualifications more
frequently responded affirmatively than respondents
with a degree level of education.
Respondents were less knowledgeable about the
principles of prudent use of antibiotics, as 54%
believed that it did not matter if the prescribed course
of antibiotics was not completed. Poor level of
knowledge was found in the younger generation of
Yemeni and Saudi Arabian participants and among all
age brackets in Uzbekistan (p = 0.006) with primary or
lower educational levels (p = 0.033).
However, it is important to note that knowledge
about allergies and adverse reactions associated with
taking antibiotics were the highest when compared
with other statements of knowledge. In fact, 57% of
respondents expected adverse reactions. Strong
knowledge was mostly found among respondents of
older, well-educated age groups in all the studied
countries (p = 0.001, p < 0.001 for country/age and
country/education, respectively). Participants aware of
adverse reactions associated with antibiotic use were
more likely to have obtained antibiotics according to a
physician’s prescription (p < 0.001, τ = 0.110).
Discussion
The present study demonstrated the high
prevalence of self-medication and inappropriate use of
antibiotics among well-educated populations of
Yemen, Saudi Arabia, and Uzbekistan. Up to 70% of
J Infect Dev Ctries 2014; 8(4):424-429.
respondents administered unprescribed antibiotics and
more than half of these unprescribed medications were
inappropriate. Our findings contribute to the evidence
of the growing tendency for self-medication among
the general population in both developed and
developing countries. Nonetheless, Asian estimates [6-
10] are higher compared with those from studies
conducted in Europe and the United States [11-16],
with prevalence rates of self-medication ranging from
3% to 60%.
The reasons for self-administration of non-
prescribed antibiotics are varied. Although poor
regulation of antimicrobials resulting from policies not
being enforced is the major factor influencing self-
medication, it is not the only one accounting for this
behavior [4,17]. Poverty, lack of access to health care,
cultural beliefs, and practice of obtaining
antimicrobials without prescriptions, particularly for
viral respiratory infections, are other driving factors
behind antibiotic self-medication in the community of
participating countries.
Non-prescription use is frequently associated with
very short courses and inappropriate drug and dose
choices [18-26]. Extrapolating from the survey results,
we estimate that every second respondent did not
complete the course of antibiotic therapy, thereby
promoting antibiotic resistance. Non-compliance was
lower in Yemen and Saudi Arabia than in Uzbekistan.
These findings correspond to other studies confirming
that patients often do not adhere to their treatment. A
patient survey in 11 countries across the world showed
that 22.3% of patients who received antibiotic
medication admitted to not finishing the therapy [27].
Moreover, patients may store antibiotics from
uncompleted courses, even beyond the expiration date,
and later self-administer these drugs for self-diagnosed
conditions or dispense them to family members and
friends [28-30].
Self-medication is associated with little guidance
regarding appropriate antibiotic selection for
individual syndromes and safe practices to minimize
adverse drug effects even when provided by a
pharmacist [21,31-33]. In our study, the majority of
respondents who self-medicate identified a private
pharmacy as the main source of medicine and
information. The potential for adverse events is
known. Generally, pharmacy staff did not inquire
about patient’s allergies, did not explain potential side
effects, and dispensed contraindicated antimicrobials
such as tetracyclines and fluoroquinolones or
parenteral antimicrobials for home use. Other risks
factors include masked diagnosis of infection disease,
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Belkina et al. – Antibiotic use in three Asian countries
drug interactions, and superinfection [12].
Furthermore, financial concerns often guide selection
of low-quality antibiotics and result in short durations
of treatment [17].
Several studies, [32,34,35] already provided
evidence of inappropriate antimicrobial use for the
treatment of bacterial infections; our results are
similar. The most common reasons for antibiotic use
were colds and upper respiratory tract infections,
where the cause is likely to be viral. For a condition to
be considered a minor ailment and self-managed
depended not only upon the severity, but on previous
experience and knowledge as well [36]. The teachers
who responded to this survey had less knowledge
about appropriate antibiotic use than one would
expect, considering their high literacy rate in
comparison with other groups of these developing
countries. We found a consistent direct link between
irrational antibiotic use and lower educational levels.
Younger, less educated women were most inclined to
self-medicate and lacked knowledge about the dangers
associated with antibiotic use. However, there was a
very robust correlation between awareness of adverse
reactions and antibiotic prescription. This correlation
suggests that respondents who were apprehensive
about antibiotic side effects did not attempt to self-
medicate and consulted their physician. A possible
explanation is that those respondents may have learned
about the adverse impact of antibiotic use from their
physician or pharmacist or from personal experience
with antibiotic side effects. General education teachers
may not be critical consumers of medicine research or
may not have time to keep up with professional
journals. However, they are primary transmitters of
knowledge, and if their health behavior is
inappropriate, it may have an effect on instilling health
values and beliefs in children.
Our findings should be interpreted within the
context of several limitations to our study. First, the
sample was confined to nations’ teachers, thereby
limiting the generalizability of the results. A second
significant limitation was the possibility of sample
bias. The respondents were all from urban areas with
higher socio-economic status and may not be
representative of the rest of the countries. Future
studies should be undertaken to investigate antibiotic
use in rural regions. Third, the results are based on
self-reported behavior, which may not represent actual
behavior. Finally, the high male-to-female ratio found
in this study is not a truly representative value for
actual gender distribution in the population.
J Infect Dev Ctries 2014; 8(4):424-429.
Our study confirms that the availability of non-
prescription antibiotics leads to inappropriate self-
medication in the communities of Yemen, Saudi
Arabia, and Uzbekistan. There is great concern
surrounding the development and spread of resistance
resulting from poor knowledge about the dangers of
self-medication and misuse of antibiotics. This study
highlights the need to take decisive policy action to
reduce non-prescribed antibiotic use. Measures may
include restricting the dispensing of antibiotics to
prescription only, enforcing supervision by regulatory
authorities, and implementing effective public
information campaigns to encourage appropriate use
of antibiotics.
Acknowledgements
We would like to thank Ludmila Kagakova and Safia
Abdulasis Alnoeman for their help with the questionnaire.
This project was supported by the grant of Charles
University in Prague (SVV 267 005).
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Corresponding author
Tatyana Belkina
Department of Social and Clinical Pharmacy
Faculty of Pharmacy, Charles University
1203 Heyrovsky Street, 50005 Hradec Kralove, Czech Republic
Phone: +420 495 067 486
Email: belkinat@faf.cuni.cz
Conflict of interests: No conflict of interests is declared.
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